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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ;." State of California I 1 - 1143506 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> (Business Profile inspection Details <br /> TP ID- ` ] n r� Inspection Type (Fill one) <br /> Site Suffix: 1 © L l V 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local '� If Referral,choose referral type(Fill one) <br /> Identifier: ° �jn 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> — - - <br /> Business or Facility Name Inspected By Inspector <br /> d <br /> e o f V r O�t 1 <br /> Physical dres 1 - I 0 aCn Esc6 <br /> o Inspection Date I r , 0 <br /> �� Time In Time Out <br /> Business Rep Title J\ . O O 0 AM 0 PM <br /> _0 PM -- - <br /> ^. operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � � <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 41 Active 0 Passenger ® Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body JS Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 00 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments �1 _ ` 5 w_� lvuU l <br /> t - Vii) lao5 OS ur,_us aconcein -- - - - <br /> J <br /> Inspection Form Included: 0i ?0, <br /> Comments Included: O, -- OL - ( 5LL��. f� �•[CJ�1on J b <br /> B siness Rep's Signature Phone Numbler inspector Signature PFTone Number <br /> -------- <br /> -- / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co : ® ■ <br />